Summary and Conclusion

the Sustainable Development Goals and the Future of Global Health

Key Points:

• From 2000, the eight Millennium Development Goals (MDGs) provided the framework for global development efforts transforming the field now known as global health. The MDGs both reflected and contributed to shaping a normative global health agenda.

• In the field of global health, the role of the state is largely considered to have diminished; however, this paper reasserts states as actors in the conceptualisation and institutionalisation of the MDGs, and illustrates how states exerted power and engaged in the MDG process. States not only sanctioned the MDGs through their heads of states endorsing the Millennium Declaration, but also acted more subtly behind the scenes supporting, enabling, and/or leveraging other actors, institutions and processes to conceptualise and legitimize the MDGs.

• Appreciating the MDGs' role in the conceptualisation of global health is particularly relevant given the transition to the MDGs' successor, the Sustainable Development Goals (SDGs). The SDGs' influence, impact and importance remains to be seen;

however, to understand the future of global health and how actors, particularly states, can engage to shape the field, a deeper sense of the MDGs' legacy and how actors engaged in the past is helpful.

Introduction

From 2000-2015, the eight Millennium Development Goals (MDGs) provided the framework for global development efforts. The MDGs shaped billions of dollars of investment, and impacted the lives of many. Advocates contend they invigorated institutions, stimulated research communities, inspired civil society movements and galvanized politicians and citizens.²²⁴ Scholars argue the MDGs represented a new ‘super norm’ dominating the global development agenda.²²⁵ Three out of the eight goals related directly to health and the other

3 Much of this chapter was published as Marten, Robert. “How States Exerted Power to Create the Millennium Development Goals and How This Shaped the Global Health Agenda: Lessons for the Sustainable Development Goals and the Future of Global Health.” Global Public Health, April 26, 2018, 1–16. https://doi.org/10.1080/17441692.2018.1468474. This is also included in Annex III.

57 five goals focused on critical determinants of health. The MDGs’ influence was pivotal to creating a normative global health agenda, which largely continues to shape the global health agenda today. Appreciating the MDGs’ role and legacy in the conceptualization of global health is particularly relevant as the world transitions from the MDGs to the Sustainable Development Goals (SDGs). The SDGs’ influence, impact and importance remains to be seen;

however, to understand global health now and in the future and assess how actors, like states, can engage to shape the field, a deeper sense of the MDGs’ origins and of how actors engaged in the past is instructive.

Defining and determining what is and what is not considered part of the global health agenda remains disputed. There is no single global health agenda.^226,227 Yet how global health is defined and understood shapes which health challenges are considered.^228,229 The definition impacts the design of how funds are raised and eventually disbursed. It influences discourse and how policymakers consider issues. It determines the education of students and future policymakers. The global health agenda can also contribute to the creation of new global health institutions like the Global Fund or GAVI, the Vaccine Alliance. In other words, the conceptualization of global health exerts power by determining the global health agenda.

As recently argued, ‘power is exercised everywhere in global health although its presence may be more apparent in some instances than others’.²³⁰

While the tremendous normative power of the MDGs is increasingly recognized, there is limited analysis considering the explicit role of state actors within the process to create the MDGs. Existing literature highlights the important role of civil society and non-governmental actors²³¹, “norm champions”²²⁵ and “well-placed individuals within the UN”

232; however, to better identify both the origins and future of global health as a field of policy action, it is necessary to reconsider how state actors engaged in this process to create the MDGs. What were state actors’ roles in the policymaking process to create the MDGs? Why and how did state actors engage to shape and influence the process?

Despite broad recognition of the MDGs’ and their role in development, their relationship to the rise of the field of global health is less explicitly acknowledged. Part of this could be the tension between the normative aspiration of global health to transcend

58 states and national borders with the reality of the MDGs and global health institutions still operating within an UN-state system. This could help explain why seminal articles assessing the transition from international to global health do not even mention the MDGs.²³³ This is somewhat paradoxical given that the MDGs had a strong health focus and that the emergence of global health in the late 1990s and early 2000s broadly coincided with the United Nations’

(UN) Millennium Declaration. The MDGs also built on previous advocacy efforts. For example, MDG 4 on child mortality built on the experience of the child-survival revolution in the 1990s.²³⁴

The MDGs also matter for global health as issues not included within the MDG agenda, like non-communicable diseases (NCDs), received reduced interest, attention and resources within the field of global health. Conversely issues included in the MDGs, like HIV/AIDS, gained disproportionate and distortionary attention possibly displacing other health spending.²³⁵ Some experts argued that the quantification of the MDGs and their targets led to “simplification, reification and abstraction” which contributed to redefining some of the priorities.²³⁶ By 2014, roughly $23 billion out of a total of $36 billion of Development Assistance for Health (DAH) was directed towards MDGs Four, Five, and Six whereas only

$611 million was directed towards NCDs.²³⁷ Moreover, since 1990 DAH associated with the MDGs increased more than any other areas.²³⁸ While this was not necessarily the case for every goal and target within the MDGs, it was the case that if a health challenge was not an MDG goal or target, it was more difficult to raise support and awareness for this issue in the MDG era. For example, anticipating this situation, former UNAIDS Director Peter Piot fiercely advocated for HIV/AIDS to be included in the MDGs.²³⁹

At their inception, the MDGs caused rigorous debate amongst academics, civil society and policymakers around the world with one early critic calling them a “Major Distraction Gimmick” ²⁴⁰ forced upon developing countries by the triad of the United States, Europe and Japan.²⁴¹ Yet these early critiques were eventually forgotten or ignored considering the power of the MDGs’ supporters, and as the MDGs became more entrenched as development policy. Indeed, a recent review²⁴² found that “only 15 percent of MDG-related publications expressed concerns with the MDGs and only one-third of these discussed intrinsic limitations. From this narrower literature, the review considers MDGs’ limitations in terms

59 of the development process ²⁴³, structure²⁴³, content²⁴⁴ as well as implementation and enforcement.²⁴⁵

Despite these critiques, an early Millennium Project report declared, that the MDGs were “the most broadly supported, comprehensive, and specific poverty reduction targets the world has ever established.”²⁴⁶ A UN MDGs final report defined them as the “most successful anti-poverty movement in history.”²⁴⁷ The MDGs reflected a departure from the 1980s Washington consensus development to a more people-centred or human development in the 1990s expressed during a series of UN conferences on development issues.²⁴⁸ As experts noted the MDGs arguably “created a new narrative of international development centred on global poverty” with the MDGs “the legitimized framework for defining what this means” and the “reference point around which international debates about development revolve.”²⁴⁰

More specifically within global health, the MDGs remained contested. The MDGs represent the apex of an extremely “vertical” (focused on specific diseases, like HIV/AIDS or malaria as opposed to a horizontal approach focused on health systems) approach to health interventions. The three health-specific MDGs focused on a small number of vertical interventions to combat specific diseases and maternal and child mortality as the most effective approach to improve health. In 2008, analysts highlighted “[t]he potentially destructive polarization” between vertical and horizontal approaches.²⁴⁹ The Maximizing Positive Synergies initiative (detailed in Section Two below) helped diffuse this tension leading to greater attention to health systems and a more integrated approach within health.

But the MDGs remained the dominant policy doctrine. In fact, it appears the MDGs dominated the agenda so much so that they even eventually contributed towards a more horizontal approach. One analysis found that “critical factors behind the recent burst of attention [to health systems] include fears among global health actors that health systems problems threaten the achievement of the health-related MDGs.”²⁵⁰ (Of course, defining health systems and how to best strengthen them to help achieve the MDGs is also heavily disputed. Health systems frameworks are strongly shaped by their authors.²⁵¹) Within global health, the MDGs shaped priorities and investments. The MDGs both reflected an emerging definition of global health, and contributed to advancing this conceptualization. They exerted power and

60 facilitated by the UN and civil society partners were enacted through and within nation states.

The role of power as a concept and framework for assessing how global health policy is determined is often overlooked. As Erasmus and Gilson argued, ‘power, a concept at the heart of the health policy process, is surprisingly rarely explicitly considered in the health policy implementation literature.’²⁵² Frameworks for understanding power remain contested and empirical evidence for applying these frameworks is often lacking. Given the importance of the MDGs in shaping the global health agenda, understanding how states engaged to create the MDGs could help illustrate how actors exert power in global health and hence inform how actors both engaged in the conceptualization of the SDGs and might engage with their implementation shaping the future of global health.

Based on published literature and unpublished policy materials, this chapter focuses on reconsidering the role of state actors as critical actors in both the conceptualization and institutionalization of the MDGs. While state engagement in the recent SDG process was more visible and legible, some states, contrary to common perceptions, were also critical actors in the creation of the MDGs. State actors within global health are sometimes overshadowed by the attention given to the proliferation of new actors, like public-private partnerships, civil society organizations or philanthropies.²⁵³ In the case of the MDGs, state actors not only sanctioned the MDGs through head of states endorsing the Millennium Declaration, but also acted more subtly behind the scenes supporting, enabling (sometimes by not blocking), and/or leveraging other actors, institutions and processes to conceptualize the MDGs.

This chapter considers why and how state actors exerted power and engaged in the MDG process, and describes the context for the case-studies on Japan and Indonesia. This chapter starts by presenting an overview of different potential frameworks for analysing the role of states in the creation of the MDGs, and selects the Barnett and Duvall framework (considering compulsory, productive, structural and institutional power) for analysis.²⁵⁴ Second, this chapter applies this framework describing and analysing how states exerted power in the creation and institutionalization of the MDGs (and emergence of the SDGs) in

61 three distinct phases (2000-2005; 2005-2010; and 2010-2015) in relation to the emergence of the field of global health. Finally, it considers and discusses the implications of this analysis for the recent transition from the MDGs to the SDGS, and what this might mean for the implementation of the SDGs and the future of global health.

Section One: Background on power analysis for global health

Power is a central concept in social sciences, but its meaning and application is heavily contested. Scholars disagree about sources of power, the role of power and how actors exert power. Indeed, one international relations scholar describes the concept of power as one of the ‘most troublesome in the field’ and argues that ‘the number and variety of definitions should be an embarrassment to political scientists.’²⁵⁵ Traditionally scholars have seen power conceptually defined by an actor or state resources like armies or navies and populations or territories. But in the second half of the twentieth century, this approach evolved to consider ‘relational power’, in other words, how actors, individually or in groups, related to each other and affected or influenced others’ behaviour. Beyond this, many debates and different approaches in terms of how to exert, frame, measure or understand power remain. Yet there is a consensus on the importance of understanding power and the lack of knowledge on how power functions.²⁵⁶ There is a similar, but slightly less mature, state of affairs in the global health literature.

As discussed in Chapter Two, there is an increasing recognition of the concept of power in global health, but discussions are still nascent.²⁵⁷ Similar to international relations, power in health remains associated with possession of or access to material resources like financing or medical equipment or drugs; however, there is an emergent recognition of ideas²⁵⁸, networks²⁵⁹, expertise and information²⁶⁰ as potential sources of power. This is critical for global health as many consider health a policy process dictated by technical choices instead of recognizing health as a profoundly political space in which various priorities and policies are fiercely contested and ideas, networks, expertise and information are deployed to advance competing approaches.²⁵⁷

62 From the international relations literature, there are a few different frameworks for understanding how power is exerted, which could be considered for global health. One of the simplest and perhaps most intuitive ways to illustrate how power is exerted is to compare hard and soft forms of power. Robert Dahl’s famous formulation of hard power is the ability of A to force B to do something it would not otherwise do (usually deploying military or economic resources). Joseph Nye’s conceptualization of soft power attracts or co-opts actors and persuades actors without the use of coercive force. In global health, Brazil’s influential role in advancing its political values on the negotiation of the Framework Convention on Tobacco Control is often cited as an example of soft power.²⁶¹ Others argued that to best advance interests, actors should seek to combine both hard and soft power to create smart power.²⁶² For example, one could consider American efforts on HIV/AIDS like PEPFAR advancing American interests in geopolitically strategic countries backed up with financial resources as an example of smart power.

Anotherframework from sociology is Lukes’ three faces of power.²⁶³ The first face of power is the ability of one actor to force another actor to do something they initially did not want to do, ie hard power. The second face of power is considered agenda setting and framing; powerful actors can control the agenda and determine who sits at the table and which issues are considered to be or not be on the agenda.²⁶⁴ The third face of power is the ability to control an actor’s thoughts. For example, one actor might be able to shape another actor’s initial interests. These three faces of power could be summarized as overt, covert or latent forms of power. This three faces of power framework was briefly applied to examine the process to create the SDGs.²⁶⁵ While the hard, soft, smart power framework is helpful for examining state actions at the international level, Lukes’ faces of power is most helpful for assessing the negotiation of policy processes as the framework illustrates how actors can shape the agenda by putting or removing issues from consideration (the second face of power) and/or controlling the terms or framework for conceptualizing issues (the third face of power).

Building on Lukes, global governance scholars Barnett and Duvall present a broader framework for understanding power, which is insightful for understanding how states negotiate policy processes. They consider power to be about relationships, and define it ‘as

63 the production, in and through social relations, of effects that shape the capacities of actors to determine their circumstances and fate.’²⁶⁶ They differentiate between four forms of power—compulsory power (such as use of military or economic force), institutional power (such as how international institutions are designed to favour one actor over another), structural power (the overall constitution or framework of actor and their roles) or productive power (control over the possession and distribution of resources).²⁵⁴For global health, one could think of a donor using funding to exert compulsory power; a well-positioned state leveraging a multilateral agency to exert institutional power; a prestigious university or NGO positioning its staff as experts to provide technical policy support as exerting structural power; and a UN agency or a private-sector actor advancing and promoting a particular agenda or approach to addressing health challenges as an exertion of productive power.

Given the breadth of Barnett and Duvall’s framework to distinguish between different forms of power, particularly to identify and illuminate ways in which power is exerted in ways usually unseen or unrecognized, the next section below applies this framework to analyse and illustrate state engagement in the creation of the MDGs.

Section Two: State Power and the creation of the MDGs Phase One 2000-2005: Conceptualization and Campaign

One year after the unanimous endorsement of the 2000 Millennium Declaration during the Millennium Summit with 149 heads of states and governments (the largest ever such gathering), United Nations’ Secretary General Kofi Annan submitted a report to the General Assembly entitled, a Roadmap towards the Implementation of the Millennium Declaration.²⁶⁷This report was adopted by the General Assembly, and recommended it be considered a ‘useful guide’ for operationalizing the Declaration. An annex to this report included the framework for the Millennium Development Goals (MDGs): eight goals, eighteen targets and forty-eight indicators. This MDG resolution, based on the Declaration approved and endorsed by heads of states and governments, would ultimately be leveraged

64 by the United Kingdom and other OECD states to exert tremendous compulsory, structural, institutional and productive power.

Recognizing the role of states in shaping policy is not to dismiss the role of message and norm entrepreneurs as well as elite technocrats highlighted elsewhere.²²⁵ Instead it is meant to reconsider these individuals’ roles as enabled by states exerting structural, institutional and productive power. For example, three of the Security Council’s five permanent five seats are held by OECD-member states, the United States, France and the United Kingdom. These states have veto or structural power over the appointment of the Secretary-General, and thus have influence over the Secretary-General’s office; a similar situation is true for other UN agencies and other parts of UN institutions. States use this structural power to install their nationals into key positions shaping policies within these institutions and establishing critical personal connections. States also leverage institutional power through the OECD and World Bank as well as the UN.

Following the Millennium Declaration and in coordination with the World Bank and OECD, a United Nations’ interagency expert group (IAEG) both reflected institutional power and exerted productive power. Co-chaired by a special adviser in the Secretary General’s

Following the Millennium Declaration and in coordination with the World Bank and OECD, a United Nations’ interagency expert group (IAEG) both reflected institutional power and exerted productive power. Co-chaired by a special adviser in the Secretary General’s